Pre-Examination Form

Recheck Exam or Lab Work
Any changes since your last visit or communication with the office? If so, describe.*
Were any medications or diets prescribed to address the original concern?*

YesNo
When was the medication(s) last given?*
What changes have you seen, if any?*
Anything else you would like us to know?

Gastrointestinal Exam
Main reason for visit*
When did symptoms start?*
How often? Last episode?*
Please describe form, color, and if any blood or mucous present*
Form examples: undigested food, bile, liquid, soft but formed, cow paddy, formed and firm
What diet is your pet on (including treats)? How much and how often?*
For diarrhea and constipation, any straining?
Is your pet on any medications (including medications given as needed)?*

YesNo
Current Medications (Please include name, dose and frequency)*
Any recent diet changes? Human food? New treats?*
Any possible or known toxin, plant or medication exposure?*
Eaten anything unusual lately (bedding, rocks, sticks, trash, clothing)?*
Appetite is*

Normal / No changeDecreasedIncreased
By how much?*
Water intake is*

Normal / No changeDecreasedIncreased
By how much?*
Do any other pets in your house have GI issues? If yes, please describe.
Anything else you would like us to know?
For diarrhea, we will likely check for intestinal parasites. If your pet defecates within 12 hours of the appointment, please bag at least a marble-sized portion. If older than 2 hours, keep refrigerated until your pet's appointment.*

I understand

Skin / Ear Exam
Main reason for visit*
When did symptoms start?*
Seeing scratching, licking, head shaking? If so, where and how often?*
Any discharge or odor? If yes, please describe.*
Any hair loss? If so, where.*
Has your pet been groomed, bathed or swimming lately?*
Is your pet on any medications (including medications given as needed)?*

YesNo
Current Medications (Please include dose and frequency)*
Current Diet*
Any known allergies?*
Any history of this issue occurring previously? If so when and how often?*
Anything else you would like us to know?
Photos of affected sites can be very helpful. Please upload if available.

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Growth / Mass Exam
Main reason for today's visit*
When was this noticed?*
How many growths / masses?*

1234 or more *Contact the hospital as additional time may be needed for your pet's appointmentOther
Location(s)?*
Does it seem tender?*
Has it changed in size, shape or color since first noticed?*
Any discharge or odor? If yes, please describe.*
Chewing or licking at area(s)?*
Anything else you'd like us to know?
Photos of affected sites can be very helpful. Please upload if available.

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Eye(s) Exam
Main reason for visit?*
When did it start?*
If your pet is squinting and does not have an appointment today, please contact the office directly.*

My pet is not squintingMy pet is squinting and has an appointment today
Any discharge seen? If so, color and appearance?*
Is your pet rubbing or pawing at their eyes?*
Any known trauma? if yes, please describe.*
Anything else you'd like us to know?

Urinary Exam
Main reason for visit*
When did this start and how often?*
Is your pet straining to urinate?**
*Please note this may be an emergency, especially for male cats. Contact the office directly if you notice straining.
Leaking urine while resting / sleeping?*
Color / odor of urine? Any blood noticed?*
Urinating inside house or outside of litter box?*

YesNoUnsure
Is your pet urinating in the same place(s)?*
History of urinary tract infections? Crystals or stones?*

YesNoUnsure
Current Diet (include name, dry or wet, amount fed and frequency)*
Any change to H20 intake?*

YesNoUnsure
Increased or decreased by how much?*
Anything else you'd like us to know?

Mobility Exam
Main reason for visit*
When did this start and how often?*
Any changes since first noticed? if yes, please describe.
Any known trauma? If yes, please describe.
Is your pet favoring a limb?*

YesNo
Which limb? Select all that apply.*

Front Right (Passenger side)Rear RightFront Left (Driver's side)Rear Left
Is your pet putting any weight on the limb?*
Does it seem to worsen after periods of activity or inactivity?*
Reluctant to go up or downstairs, jump on or off furniture?*
We recommend limiting your pet's activity until they can be examine. Leash walks only, isolate to a room or crate if unable to directly observe, carry up and down stairs if possible.
Any crying or vocalizing? If so, when?*
On any medications? Joint supplements? NSAIDs? Any human medication?*
Instructions, dosage, amount and frequency given, when last given*
Any other concerns?
Please upload if you have any videos of your pet displaying symptoms.

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Coughing / Sneezing / Upper Respiratory Exam
Main reason for visit*
When did it start?*
How often are you seeing symptoms?*
Has your pet had this issue before? If so, how often and when was the most recent episode.*
Are you seeing any discharge? If so, where from? Color?*
Has your pet been boarded, groomed, in public parks, or recently adopted?*
Is your pet on any medications (including medications given as needed)?

YesNo
Current Medications (Please include dose and frequency)*
Any changes to appetite, water intake, urination or defecation? If yes, please describe.*
Anything else you'd like us to know?

Main reason for visit*
When did this start and how often?*
Any changes since first noticed? If so, describe.*
Current Diet (include name, dry or wet, amount fed and frequency)*
Is your pet on any medications (including medications given as needed)?*

YesNo
Current Medications (Please include dose and frequency)*
Any changes to appetite, water intake, urination or defecation? If yes, please describe.*
Anything else you'd like us to know?

Privacy and Medical Records release

Section 801.353 of the Texas Veterinary Licensing Act protects your privacy by prohibiting disclosure of your pet(s) health care records (including rabies and other immunizations) without our specific authorization.
I give Northwest Veterinary Hospital permission to release information concerning the veterinary care for my pet(s):*

YesNo
I give Northwest Veterinary Hospital permission to use my pet(s) names and pictures for display, public relations and marketing.*

YesNo
By signing this form, I acknowledge I have read and agree to the missed appointment policy
Signature*
Print Name*
Should be Empty:

It's important for us to obtain your pet's full medical history prior to their appointment. We are happy to reach out to their previous veterinary office(s).